RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04187
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E2, Automated Logistical Specialist, medically separated for “chronic right knee pain,” “chronic right ankle and foot pain,” and “left knee pain,” rated 10%, 10% and 0%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  “Please consider all conditions.”  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20080903	VARD - 20090715	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain 	5299-5255	10%	Residuals of Stress Fracture, Right Knee	5299-5255	10%	20090120	
Chronic Right Ankle and Foot Pain	5284	10%	Residuals of Stress Fracture, Right Ankle	5271	10%	20090120	
			Residuals of Right Foot Stress Fracture	5284	0%	20090120	
Left Knee Pain	5099-5003	0%	Left Knee Condition	5255	NSC	20090120	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Right Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee became symptomatic in March 2008 during the physical training and rehabilitation program with no evidence of trauma.  Radiographic imaging (bone scan, X-rays, and MRI) in February and July 2008 (10 and 5 months prior to separation) documented a bony lesion at the distal femur (osteochondral defect; intercondylar femur); a normal lower leg (tibia and fibula) without evidence of stress fracture or degenerative changes; and normal bone signal, articular cartilages, menisci, and collateral and cruciate ligaments.  At a physical therapy visit in July 2008, the CI was using crutches, and had a right knee ROM of 0-140 degrees (normal) with no evidence of anterior instability, spasm, swelling, or pain; and no changes after repetition.  

At the MEB NARSUM examination in July 2008, the CI reported swelling and instability without giving way, and no further use of crutches.  She reported daily pain, 2-hour flare-ups caused by prolonged walking, and no night awakenings.  Physical examination showed an antalgic gait, tenderness of the medial tibial plateau; and no ligamentous laxity.  The knee had a normal appearance with painless motion, and no tenderness on ambulation.  Range of motion (ROM) was 0-140 degrees with no evidence of pain, weakness, or lack of endurance with repetition, and no evidence of meniscal injury.  

Radiographic evaluation (X-ray) in September 2008 (3 months prior to separation) was normal (normal alignment and joint spaces, no fracture, effusion, soft tissue abnormalities).  At a physical therapy visit dated 8 October 2008 (2 months prior to separation), physical examination showed a stable knee, a ROM of 0-135 degrees, no evidence of swelling or spasm, no interference with standing, sitting or weight bearing, and “obvious discomfort” with testing of the ligaments.  At a NARSUM reevaluation dated 23 October 2008, physical examination showed a ROM of 0-138 degrees, no evidence of instability or painful motion.  At a primary care visit dated 27 October 2008 (1 month prior to separation), physical examination showed normal appearance, pain-free motion, no tenderness on ambulation with normal gait, normal flexion and extension, and no laxity or evidence of meniscal injury.  

At the VA Compensation and Pension (C&P) examination dated 20 Jan 2009, (2 months after separation), the CI reported pain, instability, buckling, and swelling below the patella.  She reported the ability to walk 1/4 mile and stand for 15-30 minutes; and that her condition had a “moderate” effect on performing chores and exercise.  Physical examination showed an antalgic gait, with crepitus, tenderness, and a hypermobile patella with infrapatellar “puffy” soft tissue.  Range of motion was 0-140 degrees with no objective evidence of pain, and no additional limitations after repetition.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB assigned a 10% rating for the “chronic right knee pain due to femoral stress reaction” under an analogous code 5299-5255 (femur, impairment of), citing slight knee impairment and functional loss.  The VA also assigned a 10% rating using the same code based on the VA C&P examination 2 months after separation, citing objective findings of crepitation, tenderness, patellar abnormality, and normal range of motion; and no objective findings of pain or additional limitation following repetition.  

The Board considered the evidence for a higher than 10% rating.  There was no limitation of flexion or extension that supported a higher rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  The examinations proximate to separation did not demonstrate the presence of significant ligamentous instability or laxity (5257) for a higher rating.  There was no evidence of a dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) for a higher rating.  There was no fracture, non-union, or malunion of the femur or tibia resulting in a “moderate” level of impairment for a higher rating under the respective codes for long bone conditions (5255, 5262).  However, there was evidence of “slight” knee disability, crepitation, and functional loss at the NARSUM and VA exams supporting a 10% rating (based on §4.59, §4.40 and §4.45).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic right knee condition.  

Right Ankle and Foot Pain.  According to STRs and the MEB NARSUM, the CI’s right foot condition began in January 2008 (11 months pre-separation), during a road march.  Radiographic evaluations (bone scan and X-rays) in January and February 2008 (11 and 10 months pre-separation) documented a midfoot fracture (2nd metatarsal).  Midfoot tenderness was documented at visits in February and March 2008 (10 and 9 months prior to separation).  The foot and ankle were casted in March through April 2008 with subsequent improvement.  However, foot pain returned in April 2008, resulting in treatment with a CAM (controlled ankle motion) walker.  Radiographic evaluations (X-ray) in May 2008 (7 months pre-separation) showed bony (periosteal) reaction at the 3rd metatarsal.  

At a physical therapy visit in June 2008, the CI reported no pain with treadmill running.  Physical examination showed a normal gait with “discomfort” at the fracture site.  Progressive healing was noted radiographically in June 2008 (X-ray).  The CI’s right ankle pain began during physical rehabilitation in June 2008 without history of trauma.  There with persistent evidence of stress fracture noted on 7 July 2008 (bone scan) with a newly identified stress fracture of the right ankle (posterior talar dome).  At a physical therapy visit on 18 July 2008 (5 months pre-separation), the CI reported recurrence of foot pain and was using crutches.  Physical examination showed tenderness of the midfoot and normal range of motion.  At a physical therapy visit on 28 July 2008, physical examination showed dorsiflexion to 20 degrees (normal), and plantar flexion to 45 degrees (normal) after repetition, with no evidence of pain on standing or weight bearing.  At a visit with primary care on 30 July 2008, the CI reported daily foot pain with night awakenings.  Physical examination showed no evidence of tenderness, painful motion, or instability of the ankle.  There was foot tenderness at the fracture sites, with no evidence of painful or abnormal motion.  

At the NARSUM evaluation dated 30 July 2008, physical examination showed the ankle to have no evidence of soft tissue or bony tenderness, no laxity, no painful motion, and normal dorsiflexion and plantar flexion.  There was tenderness of the foot at the fractures sites with no evidence of edema, or bony or soft tissue tenderness, and full toe extension and flexion without discomfort.  At the MEB examination in August 2008 (4 months prior to separation), the CI reported inability to stand for long periods of time due to her ankle and foot, numbness or tingling in the foot, and a swollen or painful ankle.  Physical examination showed a “normal” foot examination.  Follow up radiographs (X-rays) obtained in September 2008 (3months pre-separation) described “healing” stress fractures.  At a visit with primary care on 27 October 2008 (1 month prior to separation), the physical examination showed normal gait and ankle ROM without pain or tenderness on ambulation, dorsiflexion or plantar flexion.  The foot was not specifically examined.  

At the VA C&P examination in January 2009, (2 months after separation), the CI reported pain and weakness with standing greater than 15-30 min or walking greater than 1/4 mile.  She reported pain at the posterior and lateral ankle with intermittent swelling; and that it was the cause of a fall.  Physical examination of the right foot showed an antalgic gait, and tenderness with no evidence of painful motion, swelling, instability or abnormal weight bearing.  Physical examination of the right ankle showed painful motion, with normal plantar and dorsiflexion, and no additional pain or limitation after repetition.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB assigned a 10% rating for the chronic right ankle and foot pain coded 5284 code (foot injuries, other), citing “moderate impairment” and functional loss.  The VA assigned two separate ratings for the ankle and foot.  A 10% rating was assigned for “residuals of stress fracture, right ankle” coded 5271 (ankle, limited motion of, moderate) based on the 20 January 2009 VA C&P examination (2 months post-separation), citing painful and normal ROM with no evidence of marked limitation.  

The VA assigned a 0% rating for the “residuals of right foot stress fracture” coded 5284 (foot injuries, other, moderate) based on the 20 January 2009 VA C&P examination, citing reported pain and objective tenderness resulting in mild symptoms without evidence of moderate foot injury.  

The Board first considered if separate ratings for foot and ankle disability were appropriate in this case, but members agreed that no separately ratable impairment was discernable without violation of VASRD §4.14 (avoidance of pyramiding).  

The Board next considered the evidence for a higher rating.  There was a history of fracture of the 2nd and 3rd metatarsal bones of the midfoot with incomplete radiographic healing by the time of separation.  There was evidence of normal ankle ranges of motion throughout the STR and post-separation.  There was intermittent tenderness that continued post-separation with no impact on ankle range of motion.  Therefore, there was no evidence of a ‘moderately severe’ disability at the time of separation for a 20% rating under codes 5283 (tarsal, or metatarsal bones, malunion of, or nonunion of) or 5284 (foot injuries, other).  There was no documentation of incapacitating exacerbations for a higher rating under 5003.  There was no evidence of marked limitation of motion of the ankle for a higher rating under 5271.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic right ankle and foot pain condition.  

Left Knee Pain.  According to STR and the MEB NARSUM, the CI’s left knee condition began in July 2008 (5 months pre-separation) with no history of trauma.  At a physical therapy visit on 10 July 2008, the CI reported knee pain for 2 weeks after running on the treadmill.  Physical examination showed an antalgic gait with pain during squat; tenderness of the medial tibial plateau and upper to mid tibia, with no visible edema.  Strength testing, ROM, and testing for ligamentous instability was “normal.”  Radiographs dated 16 July 2008 documented a normal left tibia and fibula with no fracture or degenerative changes.  At a physical therapy visit on 28 July 2008, the physical examination showed a left knee ROM of 0-138 degrees (normal 0-140) after repetition, with no evidence of anterior instability, spasm, swelling, or pain.  At a primary care visit 2 days later, the CI had stopped using crutches.  The physical examination showed normal appearance and motion without pain or tenderness during ambulation, however, the left medial knee (at the medial tibial plateau) was tender to palpation.  

At the MEB NARSUM examination dated 30 July 2008, the CI reported no further use of crutches, daily pain, flare ups caused by prolonged walking lasting 2 hours, and no night awakenings.  Physical examination showed tenderness of the medial tibial plateau; no ligamentous laxity; and a normal knee appearance with pain-free motion, no edema, and no tenderness on ambulation.  Left knee ROM was 0-138 degrees with no evidence of pain, weakness, or lack of endurance with repetition, and no evidence of meniscal injury.  At a primary care visit dated 6 October 2008 (2 months pre-separation), the CI reported daily pain next to the patellar tendon, worsened by maneuvering stairs.  The physical examination showed normal appearance, no tenderness on ambulation with normal gait, normal flexion and extension, and no laxity or evidence of meniscal injury.  There was tenderness over the medial knee (next to patellar ligament at the pes anserine bursa) and pain with flexion.  At a physical therapy visit dated 8 October 2008, physical examination showed a stable knee, a ROM of 0-140 degrees with repetition, no evidence of swelling or spasm, no interference with standing, sitting or weight bearing, and “obvious discomfort” with testing of the ligaments.  

At a NARSUM reevaluation dated 23 October 2008, the CI requested reevaluation of the left knee for a change in pain location and no other new symptoms.  The physical examination showed tenderness over the pes anserine bursa, a ROM of 0-140 degrees with painful motion at end range, and no evidence of instability, weakness, incoordination or lack of endurance.  The examiner diagnosed “pes anserine bursitis, medically acceptable.”  At a primary care visit dated 27 October 2008 (1 month pre-separation), the CI reported 3 days of constant medial knee pain radiating to the shin with no history of trauma.  The physical examination showed only tenderness of the pes anserine bursa, with normal pain-free ROM, no laxity, normal gait, and no tenderness on ambulation.  

At the VA C&P examination dated 20 January 2009, the CI reported weakness, swelling inferior to the knee, constant pain diffusely about the knee and radiating down the leg, with no buckling, or locking.  She reported ability to walk ¼ mile and stand for 15-30 minutes; and a “mild” effect on performing chores and exercise.  Physical examination showed an antalgic gait, with tenderness, and a hypermobile patella with infrapatellar “puffy” soft tissue.  There was no crepitation or instability, and no evidence of meniscal injury, abnormal bursae or tendons.  Range of motion was 0-140 degrees with no objective evidence of pain, and no additional limitations after repetition.  The examiner diagnosed “left knee pain- no other diagnosis can be made, hypermobile patella.”  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated 0% for the “left knee pain without any radiographic structural abnormality,” analogously coded 5099-5003 code (degenerative arthritis), citing no instability and normal ROM.  The VA denied service connection for the left knee condition, coded 5255 (femur, impairment of) based on lack of chronicity.  

The Board considered the evidence for a higher rating.  Several pre-separation visits documented tenderness at the pes anserine bursa that did not persist to the post-separation VA C&P examination, therefore establishing lack of chronicity.  There was no radiographic evidence of degenerative arthritis.  There were several pre-separation visits documenting pain-free ROM, with only one documenting pain at end range of flexion.  There was no evidence of swelling, muscle spasm or satisfactory evidence of painful motion; and no evidence of compensable limitation of motion for a rating higher than 0%.  Although coding under 5019 (bursitis) would be more descriptive of the pathology, it would be of no benefit to the CI.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left knee pain condition.  

BOARD FINDINGS:  In the matter of the chronic right knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic right ankle and foot pain conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140928, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

07 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018262 (PD201404187)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA